eXtensions - The Wednesday File (10): The Best of iOS Health; Caremap from Boston Children's Hospital; and Plethysmography

By Graham K. Rogers

Apple tends to do a lot of work behind the scenes, so its announcements at WWDC on IR and VR showed well developed products. The same is happening with health care in which there is growing investment. With strategic acquisitions and hires, Apple has positioned itself to take the lead in healthcare and data services.

The Health App and related technologies interested me from the time they were introduced, but I began to look more closely in to the possibilities when Apple arranged for me to speak to Dr. Richard Milner of Ochner Health System who was attending a health conference here.

Before interviewing him, I had time to look round the exhibition that was running concurrently and I came away impressed with the potential. This is, after all, estimated to be a $3 billion industry. As well as a look at some devices that work with the Health App (and some that do not), I have looked closely at the current version of the app itself.

Recently I was intrigued when it was revealed that Tim Cook had been testing a device that linked with the Apple Watch and, apparently, allowed non-invasive checking of blood glucose levels. With the number of diabetes sufferers, this would be an important step forward. During the WWDC keynote, Kevin Lynch mentioned briefly that external devices would be able to link to the Apple Watch in the future.

Cook removed the device for a public meeting. A part of the rumor suggested this could use blue light, but my own checks, and discussion with researchers, pour cold water on this specific idea. It may simply be that the device uses non-FDA approved methods to give an estimated reading of conditions after eating or exercise, to inform users who are interested enough to make any adjustments. Blue light is at the wrong end of the spectrum for such analysis, with most systems under investigation using red, infrared or low power radio: passing a signal through a thin layer of skin, such as the earlobe, noting signal differences.

Following a discussion in reader comments on Seeking Alpha I was given information by an investor who had been interested in a company that had been developing an arm-band type sensor sytem that uses a number of sensors to take readings from the body. Some of this information is outlined by Jonathan Strickland "How the BodyMedia Fit Works". Certain of the readings relate to caloric burn, and other activities are recorded.

That initial development had a glucose measuring prototype added I was told and was tested thoroughly by researchers at three universities, with results close to the current finger prick methodology. This is the standard test, using the patient's blood with a reactant for a reading. Despite the research and the results, it was rejected by the FDA because the method does not measure a body fluid. The investor is confident that Apple's new interest in such technologies may succeed because of the general interest, the momentum coming out of Cupertino, and because Apple could also make a push in Europe first.

While Apple supports developers who are interested in both invasive and non-invasive technology, the company is not interested itself in going head to head with the FDA, partly because of the bureaucracy and the delays this could cause with new products: better to have a 3rd party, external device that links via Bluetooth.

One of the comments in that Jonathan Strickland article concerned the range of data that could be recorded: "BodyMedia's Activity Manager includes a food diary feature that lets you keep track of everything you eat. The food database is extensive. You just have to enter information about what - and how much - you've had to eat for each meal." This is closely related to some of the rumoured functions of the device that Cook has been using: the ability to indicate changes automatically.

Recording of data has been one of the biggest drawbacks for me when using Apple's Health App. I have it set up for automatic inputs, including from the Apple Watch, of exercise data (mainly walking), steps, flights of stairs, blood pressure, sleep, calorific burning, and blood pressure, which I measure using the Withings device I have. The app was updated by Nokia (the Withings parent company now) this week and is now called Nokia Health Mate, although it was not working properly when I installed the new version. There will be rebranding of the hardware devices. Some of these are available in Bangkok, still under the Withings name.

The Withings app that I use controls the blood pressure monitor. Data from that is sent to Apple's Health app, but it is a 2-way street with Health data appearing in the Withings app. I do tend to refer mainly to the Health app, but the Withings app displays data in different ways, so a variation on the same picture is possible. The update has changed the displays.

This sharing of data also happens with Cardiogram, an app that found some fame recently when its developers reported a correlation between heart data recorded by the Apple Watch and their own ResearchKit-based study. Not long after, a survey conducted by Stanford found that the Apple Watch achieved the lowest overall error in both heart rate and energy expenditure: this was in my comments on blue light solutions.

The Health app is somewhat underused, and (as above) much of the data that could be used needs to be entered manually, which may deter some users. An example is Water in the Nutrition section, along with Carbohydrates, Niacin, Iron, Chromium from a list of 39 essentials. Although related apps are offered, as far as I can tell, any information here would need to be entered manually. Unless there is an essential need to record such information, many would be hesitant (Wuerthele - below - calls this apathy) to enter data, unless it were done automatically.

Apple iOS Health app

In the same Health Data panel there is a link to a Health Records section, which in my case remains empty. It allows the user to grant access to sources that could both download and update medical records as needed. If used, this would allow far more efficient medical care, for example for old people, or those travelling. Imagine being on vacation, in a foreign country and, if needed, health care professionals could have access to records, enabling full and timely treatment.

I do have a lot of information that only I can see on my iPhone, although it is possible to show this to medical professionals (or share), should they be interested. In recent visits, when I checked blood-glucose levels, the doctors were only interested in the results from their own clinic; and my occasional high blood pressure readings moved the doctor less than I expected, which I guess should be reassuring. What I do notice however, is that all of my notes, that are retrieved each time I visit, are on paper and the staff add to the file each time I visit.

When I arrive at the hospital, however, and I am asked for my name and other details, the personal information is on a database: the reference number is used to fetch those medical notes.

Last month, it was announced that Apple had acquired Lattice Data along with some 20 engineers. Lattice specialises in Dark Data: "the mass of unorganized information stored in computer networks that is not in a proper format for companies to analyze or tap into" and uses AI to impose some form of order onto this.

As this information becomes more widely known, so the potential is being discussed by more people. Mike Wuerthele on AppleInsider this week, commenting on a report from CNBC, writes about "a digital medical record initiative to simplify getting all of a patient's information to every caretaker that needs it". This sounds as if it could be related to the Lattice Data acquisition. However, as Wuerthele concedes, a lot depends on patient apathy, as I illustrate in my own reluctance to use non-automatic data sections of the Health app.

The article has a link to another that Wuerthele wrote on the Boston Children's Hospital Caremap app. This is available here and allows the user to opt for Boston Children's Hospital, Duke Children's, or to use this without registering with those units. I did register, but instead of describing a child's health wrote that I was reviewing the app, in case anyone does read it.

Boston Children's Hospital's Caremap app

As part of the setting up, details and conditions of the subject are entered (spelling error in Step 5, "emgergency"), including medical procedures. Families can track, "parameters like exercise, mood, seizure frequency, pain, and sleep". If you have ever known someone with a young child who has health problems, this could be of assistance. This is illustrated in the movie, As Good as it Gets: Carol Connelly (Helen Hunt) maintains scrupulous records of her son's illnesses and allergies which are (almost) killers. Overall, this beta app is a good start to more integrated use of personal devices in health care.

In another posting, Patently Apple mentions a Tim Cook interview in which he discusses Apple's plans to work with the Veterans' Affairs department and that Apple had hired Stanford's Dr. Sumbul Desai to work on Health Services. The article reports that "Apple would be trying to re-create what it did with music" - a centralized management system.

The automation of health records is the sort of thing that Apple does so well, working behind the scenes, solving problems and hiring some of the best talent. Some were surprised at WWDC - after months of suggesting Apple was doing nothing and that products needed to be updated - when a range of new hardware was introduced along with demonstrations of AI and VR solutions. These were not put together the weekend before WWDC in someone's garage. The same appears to apply to Project Titan that Tim Cook mentioned (not by name) recently, confirming that much development work has been going on.

The problem with such vast amounts of data - and private data at that - is the lack of security. In Charles Arthur's, Overspill, this week, he links to an article on Gizmodo (Kashmir Hill and Surya Mattu) who outline situations in which people have been contacted concerning their health. This why we need encryption and it was good to see that the EU has proposed amended regulations that would require end-to-end encryption when available and forbid backdoors. Of course, the one country that seems desperate to ensure that encryption is crackable and that there are backdoors, is currently negotiating its exit from the EU.

When Apple is ready - hardware, software, car technology, health applications - announcements will be made. Rather than rushing a product out, Apple prefers to refine and make things work properly first.

While looking through information in preparation for the above, I found a new word: Plethysmography. Patently Apple outlines a new Apple Watch feature that uses this to measure respiration rate: part of Apple's move into health and related technologies. Let me cheat and use Apple's own internal dictionary information (accessed by pressing the Control key when a mouse button or trackpad is used):

A photoplethysmogram (PPG) is an optically obtained plethysmogram, a volumetric measurement of an organ. A PPG is often obtained by using a pulse oximeter which illuminates the skin and measures changes in light absorption. A conventional pulse oximeter monitors the perfusion of blood to the dermis and subcutaneous tissue of the skin. With each cardiac cycle the heart pumps blood to the periphery.

This has some echo of information above about the ways differences are used to detect various inputs. The article adds, "the light information of various wavelengths may be used to compute such a time delay as a function of time, and a respiratory rate signal may be determined accordingly." That "various wavelengths" is of great interest to me as this could suggest that a future Apple Watch could have not only green LEDs but different colors as well.

Blue perhaps?

Graham K. Rogers teaches at the Faculty of Engineering, Mahidol University in Thailand. He wrote in the Bangkok Post, Database supplement on IT subjects. For the last seven years of Database he wrote a column on Apple and Macs. After 3 years writing a column in the Life supplement, he is now no longer associated with the Bangkok Post. He can be followed on Twitter (@extensions_th)